Female Trainees Still Dissuaded by Electrophysiology ‘Old Boys’ Club,’ Says ACC Survey

More role models are needed to bridge the enormous gender gap in the field of electrophysiology (EP), according to a survey conducted by the American College of Cardiology (ACC). Female trainees also cite radiation safety concerns and not wanting to deal with a clubby network of older, white men as reasons for not choosing the specialty.

“We can help change the culture so future females that go through the ranks don't have to be subjected to the old boys’ club,” noted senior author Edward L. O’Leary, MD (University of Nebraska Medical Center, Omaha). “The biggest thing standing in the way is female leadership and mentorship.” That takes more women first authors on research papers as well as advocacy within institutions and within departments, he added. At his own center, concerted efforts have led to the number of female first-year general CV fellows-in-training (FITs) increasing from one in five in 2019 to four in seven in 2021.

“Like so many other things, once you get a critical mass, it'll potentiate,” he said. “People start to see that you are making these diversity changes and it makes your program all that more inviting, regardless of where you are located.”

The ACC’s results, with lead author Nashwa Abdulsalam, MBBCH (University of Washington, Seattle), were published today in the Journal of the American College of Cardiology.

Saima Karim, DO (Case Western Reserve University, Cleveland, OH), said surveys like this are important first steps in documenting the bias that so many in the field know is out there.

“Historically there have not been many women in positions of leadership, and as time goes on it becomes a self-fulfilling prophecy, even in the larger programs,” she told TCTMD. In terms of experiencing harassment and an ‘old boys’ club’ mentality, Karim said, “I think if you talk to any woman in EP, you'd be hard pressed to find someone that hasn't experienced it to some degree.”

Low Interest, Multiple Barriers

With a 30.5% response rate, the anonymous online survey included 933 cardiovascular FITs (30% women): 129 in EP, 259 in interventional cardiology, and 545 in other specialties or undecided. Only one in seven FITs expressed an interest in a career in electrophysiology. Of those, 84% were men.

A strong interest in the field, opportunity to perform hands-on procedures, and the analytical process that goes into clinical decision-making were the biggest influences for choosing EP among both men and women. However, more women than men said having a female role model would influence their decision (P = 0.001).

Factors most associated with not choosing an electrophysiology career were greater interest in another field, procedural length, and a desire for a different type of patient contact. Other negative factors sited by FITs not interested in EP were little flexibility in job prospects, procedure length, technical difficulty, physically demanding nature of the job, anticipated pressure on the job, need to shorten training to repay student loans, old boys’ club culture, lack of female role models, and gender discrimination or harassment.

”The long training, long work hours, poor work-life balance, significant radiation exposure all played into the decision making to some level,” said one female FIT who took the survey. Two others said they chose interventional cardiology instead. For one of them, the training requirement of only 1 year after general fellowship was seen as a significant advantage over EP. The other said her program had many female interventional cardiologists, which influenced her even further. She also said the lack of female faculty, diversity, and inclusion “left zero desire for me to pursue EP as a specialty.”

What Can Be Done?

In an editorial accompanying the study, researchers led by Erin D. Michos, MD, MHS (Johns Hopkins University School of Medicine, Baltimore, MD), say the survey findings are clear affirmation that representation matters.

“Female EP cardiologists need to be visible to the pipeline, to attract and retain the early learners such as undergraduate students, medical students, and internal medicine residents,” Michos and colleagues write. They add that the overall scarcity of women in the field emphasizes the importance of male allies acting as mentors and sponsors to help women climb the ladder.

Importantly, they also urge that training be shortened, since it coincides with childbearing years and is viewed as being too long in general.

“A shortened training model, such as 2/2/2 or 3/2/2 of respective years for internal medicine/general cardiology/EP training, may be an effective strategy of encouraging and retaining talent, both men and women, into EP,” Michos et al write.

O’Leary agreed. “We need a complete overhaul of the system, and I do think that will resonate more with females than males because they want to get on with their lives and have families,” he said. In their article, O’Leary and colleagues also note that many trainees are not exposed to electrophysiology until late in medical school, which they say could be another problem remedied by changes to training models.

Karim added that even though it is prohibited, many trainees still report being asked during interviews questions about their marital status or about whether they have children, which is just one more barrier that makes EP training tougher for women than men.

“It's sort of a hidden blessing because you know not to go into that program, but we need to be stricter and not let programs get away with doing that,” she said.

Michos and colleagues advocate for protected time during pregnancy, including time off, as well as putting lactation spaces for breastfeeding mothers close to procedural areas, using time off from procedures to perform other rotations, and accommodating parental leave for new mothers and fathers.

“[Electrophysiology] is an excellent field and it's very feasible to have a balance of work and life,” Karim observed. “It also helps to have understanding partners along with understanding faculty and leadership. The impetus to improve the ratio of women trainees clearly needs to come from leadership.”